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Revascularization for Acute Coronary Syndromes

By

Ranya N. Sweis

, MD, MS, Northwestern University Feinberg School of Medicine;


Arif Jivan

, MD, PhD, Northwestern University Feinberg School of Medicine

Last full review/revision Jun 2022| Content last modified Sep 2022
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Topic Resources

Revascularization is the restoration of blood supply to ischemic myocardium in an effort to limit ongoing damage, reduce ventricular irritability, and improve short-term and long-term outcomes in patients with acute coronary syndromes Overview of Acute Coronary Syndromes (ACS) Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on degree and location of obstruction and range from unstable angina to non–ST-segment elevation... read more . Modes of revascularization include:

Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction

Immediate reperfusion is not as urgent in patients with uncomplicated non–ST-segment elevation myocardial infarction (NSTEMI), in whom a completely occluded infarct-related artery at presentation is uncommon, or in patients with unstable angina who respond to medical therapy. Such patients typically undergo angiography within the first 24 to 48 hours of hospitalization to identify coronary lesions requiring PCI Percutaneous Coronary Interventions (PCI) Percutaneous coronary interventions (PCI) include percutaneous transluminal coronary angioplasty (PTCA) with or without stent insertion. Primary indications are treatment of Angina pectoris... read more Percutaneous Coronary Interventions (PCI) or CABG Coronary Artery Bypass Grafting (CABG) Frontal and lateral chest x-ray of a patient post coronary artery bypass surgery showing sternal sutures (black arrow) and surgical clips (red arrow). Coronary artery bypass grafting (CABG)... read more Coronary Artery Bypass Grafting (CABG) .

A noninterventional approach and a trial of medical management are used for patients in whom angiography demonstrates

  • Only a small area of myocardium at risk

  • Lesion morphology not amenable to PCI

  • Anatomically insignificant disease (< 50% coronary stenosis)

  • Significant left main disease in patients who are candidates for CABG

Further, angiography or PCI should be deferred in favor of medical management for patients with a high risk of procedure-related morbidity or mortality.

By contrast, patients with persistent chest pain despite maximal medical therapy or complications (eg, markedly elevated cardiac markers, presence of cardiogenic shock, acute mitral regurgitation, ventricular septal defect, unstable arrhythmias) should proceed directly to the cardiac catheterization laboratory to identify coronary lesions requiring PCI or CABG.

As in patients with stable angina Angina Pectoris Angina pectoris is a clinical syndrome of precordial discomfort or pressure due to transient myocardial ischemia without infarction. It is typically precipitated by exertion or psychologic stress... read more , CABG has historically been preferred over PCI for patients with left main or left main equivalent disease (although the data supporting this practice are changing) and for those with left ventricular dysfunction or diabetes. CABG must also be considered when PCI is unsuccessful, cannot be used (eg, in lesions that are long or near bifurcation points), or causes acute coronary artery dissection.

Fibrinolytics are not indicated for unstable angina or NSTEMI. Risk outweighs potential benefit.

ST-Segment Elevation Myocardial Infarction

Emergency PCI is the preferred treatment of ST-segment elevation myocardial infarction (STEMI) when available in a timely fashion (door to balloon-inflation time < 90 minutes) by an experienced operator (1 General reference Revascularization is the restoration of blood supply to ischemic myocardium in an effort to limit ongoing damage, reduce ventricular irritability, and improve short-term and long-term outcomes... read more ). Indications for urgent PCI later in the course of STEMI include hemodynamic instability, malignant arrhythmias requiring transvenous pacing or repeated cardioversion, and age > 75. If the lesions necessitate CABG, there is about 4 to 12% mortality and a 20 to 43% morbidity rate.

If there is likely to be a significant delay in availability of PCI, thrombolysis should be done for STEMI patients meeting criteria (see table Fibrinolytic Therapy for STEMI Fibrinolytic Therapy for STEMI Fibrinolytic Therapy for STEMI ). Reperfusion using fibrinolytics is most effective if given in the first few minutes to hours after onset of myocardial infarction. The earlier a fibrinolytic is begun, the better. The goal is a door-to-needle time of 30 to 60 minutes. Greatest benefit occurs within 3 hours, but the drugs may be effective up to 12 hours. Used with aspirin, fibrinolytics reduce hospital mortality rate by 30 to 50% and improve ventricular function. Prehospital use of fibrinolytics by trained paramedics can significantly reduce time to treatment and should be considered in situations in which PCI within 90 minutes is not possible, particularly in patients presenting within 3 hours of symptom onset.

Regardless, most patients who undergo thrombolysis will ultimately require transfer to a PCI-capable facility for elective angiography and PCI as necessary before discharge. PCI should be considered after fibrinolytics if chest pain or ST-segment elevation persists 60 minutes after initiation of fibrinolytics or if pain and ST-segment elevation recur, but only if PCI can be initiated < 90 minutes after onset of recurrence. If PCI is unavailable, fibrinolytics can be repeated.

Table

General reference

  • 1. Lawton JS, Tamis-Holland JE, Bangalore S, et al: 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the ACC/AHA Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 79(2):e21–e129, 2022. doi: 10.1016/j.jacc.2021.09.006

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